quality
TRANSCRIPT
Quality Management
System
A multidisciplinary, systematic quality assessment and performance improvement framework
Our Goal: To improve patient outcomes, and reduce the risks associated with patient safety in a manner that embraces the mission of the hospital.
Quality Management System
“Problems” are usually due to PROCESS
failures, not PEOPLE failures!
People vs. Processes
Identify an “opportunity” (problem) Figure Out what happened (the
process) Explore why the process failed Identify possible improvements;
implement those Monitor the improvements
How does Quality Assessment -Performance Improvement work?
Antibiotic selection Preop dosing time Postop dosing Therapy to prevent VTE (blood clots) Temperature maintenance Glucose control Patient Experience: Nurse communication, Room
cleanliness, info about medications, etc. National Healthcare Safety Network: hospital-
associated infections, employee flu vaccine rates
Examples of Quality Measures
DEC JAN FEB0
10
20
30
40
50
60
70
80
90
100
80
9399
22
44
91
Press Ganey: Extent to which nurses checked ID by DOS
InpatientAS
All P
ressG
Aney P
erc
enta
ge
Current PI Project
There were 9 patient falls in 2010. A team began working to reduce the number of falls, researched best practices, and implemented improvements.
Results: 2010 patient falls = 9 (79 per 100,000 patient days) 2011 patient falls = 5 (44 per 100,000 patient days) 2012 patient falls = 1 (9 per 100,000 patient days)
Patient Fall Prevention project
Statistics are posted on HospitalCompare website. Lots of media attention about hospital errors. Many states have laws requiring public reporting of
errors. Poor performance results in decreased
reimbursement. MOST IMPORTANT: Stellar patient outcomes,
doing the right thing the right way for every patient.
Transparency
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